Devika Nair1,2, Maie El-Sourady3, Kemberlee Bonnet4, David G Schlundt4, Joseph B Fanning5, Mohana B Karlekar3. 1. Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Center for Health Services Research, Nashville, Tennessee, USA. 2. Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA. 3. Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA. 4. Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA. 5. Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee, USA.
Abstract
Background: Goals of care (GOC) conversations are critical to advance care planning but occur infrequently in nephrology. National workshops have improved trainee comfort with initiating GOC conversations but lack interface with palliative subspecialists and can incur travel-related costs. We developed an educational intervention focused on GOC conversations for nephrology trainees that incorporated into routine schedules and offered feedback from palliative subspecialists. Objective: To explore barriers and facilitators to discussing GOC and uncover perceptions of GOC-related behavior change post-intervention. Design: Qualitative study. Setting/Subjects: Sixteen nephrology trainees at an academic medical center. Measurements: Analyses of semistructured interviews occurred in phases: (1) isolation of quotes; (2) development of a coding system; and (3) creation of a framework of interrelationships between quotes using an inductive/deductive approach. Results: We captured the following themes: (1) prior knowledge (ability to define GOC, knowledge of communication frameworks and prognostic data, exposure to outpatient GOC conversations; (2) attitudes related to GOC conversations (responsibility, comfort, therapeutic alliance, patient preparedness, partnership with care teams); and (3) potential change in behaviors (increased likelihood to initiate GOC conversations early, more accurate identification of patients appropriate for a GOC conversation). Conclusions: Prior knowledge of, exposure to, and attitudes toward advance care planning were key determinants of a nephrology trainees' ability to initiate timely GOC conversations. After our intervention, trainees reported increased comfort with and likelihood to initiate GOC conversations and an improved ability to identify appropriate candidates. Our intervention may be a novel, feasible way to coach nephrologists to initiate timely GOC conversations.
Background: Goals of care (GOC) conversations are critical to advance care planning but occur infrequently in nephrology. National workshops have improved trainee comfort with initiating GOC conversations but lack interface with palliative subspecialists and can incur travel-related costs. We developed an educational intervention focused on GOC conversations for nephrology trainees that incorporated into routine schedules and offered feedback from palliative subspecialists. Objective: To explore barriers and facilitators to discussing GOC and uncover perceptions of GOC-related behavior change post-intervention. Design: Qualitative study. Setting/Subjects: Sixteen nephrology trainees at an academic medical center. Measurements: Analyses of semistructured interviews occurred in phases: (1) isolation of quotes; (2) development of a coding system; and (3) creation of a framework of interrelationships between quotes using an inductive/deductive approach. Results: We captured the following themes: (1) prior knowledge (ability to define GOC, knowledge of communication frameworks and prognostic data, exposure to outpatient GOC conversations; (2) attitudes related to GOC conversations (responsibility, comfort, therapeutic alliance, patient preparedness, partnership with care teams); and (3) potential change in behaviors (increased likelihood to initiate GOC conversations early, more accurate identification of patients appropriate for a GOC conversation). Conclusions: Prior knowledge of, exposure to, and attitudes toward advance care planning were key determinants of a nephrology trainees' ability to initiate timely GOC conversations. After our intervention, trainees reported increased comfort with and likelihood to initiate GOC conversations and an improved ability to identify appropriate candidates. Our intervention may be a novel, feasible way to coach nephrologists to initiate timely GOC conversations.
Entities:
Keywords:
advance care planning; communication skills; end-of-life care; goals of care; medical education; palliative care; qualitative research
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